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}� APPLICATION FOR PERMIT r <br /> SAN JOAQUIN COUNTY PUBLIC HEATTH SERVICES <br /> ENVIRON11ENTAL HEALTH DIVISION <br /> 445 N SAN JOAQUIN, PHONE (209)458--3420 <br /> MAY 0. 5 1993 P O BOX 2009, STOCKTON, CA 95201 <br /> ENVIRONMENTAL HEALTH PERMIT EXPIRES' 1 YEAR FRPM DATE S <br /> UED <br /> PERMIT/SERVICES <br /> (Complete in Triplicate) <br /> Application is hereby made.to San Joaquin County for a permit to construct and/or install the work herein described. This <br /> application is made in compliance with San Joaquin County ordinance No. 549 and 1862 and the Rules and Regulations of San <br /> Joaquin County Public Health Services. <br /> JLot Size/Acreage <br /> Job Address City <br /> A-7, <br /> 4-...T�✓�! <br /> Owner's-Name Address m � `I Phone <br /> i <br /> Contractor <br /> Address ? fCC� License No. ZZ Phone <br /> TYPE OF WELL/PUMP: NEW WELL ❑ WELL FIEPLACEMENT n DESTRUCTION ❑ Out of Service well ❑ <br /> PUMP INSTALLATION O SYSTEM REPAIR ❑ OTHER ❑ Monitoring Well <br /> DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> " INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS f f <br /> Cl Industrial ❑ 0 n Bottom 11 Manteca Dia. of Well Excavation Dia. at Well Casing <br /> [7 Domestic/Private ravel Pack ❑ Tracy Type of Casing_ Specifications <br /> i'1 Public f-T Other (-1 Delta Depth of Grout Seal Type of Grout�Q <br /> I I Irrigation ._.._.Approx. Depth I I Eastern Surface Seal Installed by <br /> Repair Work Done L7 Type of Pump H.P. State Work Done _ <br /> Well Destruction ❑ Well Diameter Sealing Material.& Depth <br /> Depth Filler Material & Depth <br /> TYPE OF SEPTIC WORK: NEW INSTALLATION I I REPAIR/ADDITION 1 1 DESTRUCTION 1 I (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation will some: Residence— Commercial.—.. Other <br /> Number of living units: Number of bedrooms <br /> Character of twil to a depth of 3 feet: Water table depth <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well Foundation Property Line <br /> LEACHING LINE ❑ No. a Length of linea Total length/size <br /> FILTER BED 0 Distance to nearest: Well Foundation Property Line <br /> SEEPAGE PITS i I Depth Size Number <br /> SUMPS 0 Distance to nearest: Well Foundation Property Line <br /> DISPOSAL PONDS 0 <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin County <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of Californla." <br /> The applican t call r all requirodi c ions.( plate drawing on r ree side. <br /> .5— <br /> Signs- Title: /�' - Date: <br /> FOBJISPARTMENT USE ONLY a <br /> Application Accepted by Date0-1-:5--AZY <br /> `' <br /> Pit or Grout Inspection by Date Final Inspection by Date � lf <br /> Additional Comments: <br /> Applicant - Return all copies to: San Joaquin County Public Health Services L90 <br /> Environmental Health Permit/Services <br /> 445 N San Joaquin, P O Box 2009, Stkn, CA 95201 !. <br /> FEE AMOUNT DUE AMOUNT REMITTED CK RECEIVED 9Y DATE PERMIT NO. <br /> INFOEN 13.24 MEV.1 5; OY03 <br /> CASH <br /> EH 14.2e <br />